Violence risk profile of medium- and high-security NGRI offenders in Belgium

Under Belgian law, offenders not guilty by reason of insanity (NGRI) are committed by the courts to forensic mental health treatment. The use of violence risk assessment tools has become routine in these settings. However, there are no national statistics regarding violence risk assessment in the Belgian forensic population. A study was undertaken to collect risk assessment data (PCL-R, VRAG, HCR-20) on a large cohort of forensic patients committed to Medium Security units in the Flanders region and in High-Security units in the Walloon region. Flemish patients were expected to present a lower risk compared with their Walloon counterparts. Instead, data yielded by a structured risk assessment method demonstrate the opposite. Moreover, the majority of patients in Flemish facilities had committed violent offenses and were institutionalized for shorter periods whereas the majority of Walloon patients had committed sexual offenses and were institutionalized for markedly longer periods.     

Applying a forensic actuarial assessment (the Violence Risk Appraisal Guide) to nonforensic patients

The actuarial Violence Risk Appraisal Guide (VRAG) was developed for male offenders where it has shown excellent replicability in many new forensic samples using officially recorded outcomes. Clinicians also make decisions, however, about the risk of interpersonal violence posed by nonforensic psychiatric patients of both sexes. Could an actuarial risk assessment developed for male forensic populations be used for a broader clientele? We modified the VRAG to permit evaluation using data from the MacArthur Violence Risk Assessment Study that included nonforensic male and female patients and primarily self-reported violence. The modified VRAG yielded a large effect size in the prediction of dichotomous postdischarge severe violence over 20 and 50 weeks. Accuracy of VRAG predictions was unrelated to sex. The results provide evidence about the robustness of comprehensive actuarial risk assessments and the generality of the personal factors that underlie violent behavior.     

Prospective Replication of the Violence Risk Appraisal Guide in Predicting Violent Recidivism Among Forensic Patients

An exhaustive survey of a cohort of forensic patients provided an opportunity for a prospective replication of the predictive accuracy of the Violence Risk Appraisal Guide (VRAG). Data collected during the original survey also permitted a test of the predictive accuracy of clinical assessments of risk on the same cohort. The VRAG yielded a large effect size in predicting violent recidivism (ROC area = .80) over a constant 5-year follow-up and performed significantly better than averaged clinical opinions. The superiority of the VRAG was also observed at very short follow-up times and for very serious violence. Moreover, for 16 subsamples, observed rates of violent recidivism did not differ significantly from the expected rates. VRAG score was unrelated, and clinical judgments inversely related to violent recidivism in the small low-risk sample of female forensic patients. The authors conclude that, regardless of length of opportunity or severity of outcome, actuarial methods are more accurate than is clinical judgment.     

Prediction of violent and sexual offences: A replication study of the VRAG in Switzerland

Abstract

The Violence Risk Appraisal Guide (VRAG) is a widely used actuarial risk assessment instrument and has been validated in different countries. However, there is no investigation supporting the predictive accuracy of the VRAG in the German language area. The VRAG scores of 79 violent and sexual offenders in Switzerland were assessed based on data from their psychiatric expert opinions. The VRAG scores were compared to subsequent recidivism as shown in the official criminal records. Consistent with past research in the English language area, the VRAG yielded a satisfying predictive accuracy (ROC area = .73), demonstrating its usefulness for risk assessment of violent delinquency in the Swiss cultural and German language area.     

Medical school forensic psychiatry units in health care delivery facilities rather than criminal justice institutions: an alternative model

We have presented a model for developing forensic psychiatric treatment and teaching services of a medical school Department of Psychiatry, but where these services are the basic comprehensive health care delivery system for the entire community. These offer consultative and treatment services for adult and family court clinic, psychiatric forensic services, of forensic psychiatry open bed and medium security-type bed, as well as day hospital and outpatient services. All of these are sited in the normal health care delivery system of the university teaching hospitals and its patient treatment, teaching, and research facilities. Consultative services are offered on request to the criminal justice system, but the basic health care delivery system is controlled administratively by the ordinary university teaching hospital authorities and exists as a one of a kind unit at the Royal Ottawa Hospital. The Royal Ottawa Hospital is a private nonprofit hospital, with its own Board of Trustees, and is affiliated with the medical school, as part of a major university network. We believe it important to present this model for an overall forensic psychiatric service, in contradistinction to the more commonly established forensic psychiatric facilities in state mental hospitals, in a special facility for the criminally insane, or in a criminal justice system institution such as a penitentiary. We believe that our model for forensic psychiatric facilities has great advantages for the patient. Here the patient is treated in a specialized facility (as all psychiatric patients with specialized problems should be); but one which is a specialized forensic facility, within the range of specialized psychiatric facilities that are needed by an urban community.(ABSTRACT TRUNCATED AT 250 WORDS)     

关于进一步规范精神疾病司法鉴定执业活动的几点思考

精神疾病司法鉴定问题一直以来备受公众责难,处理不好将影响社会公共安全和秩序,并对精神疾病患者的合法权益造成损害。解决此问题的关键是要认清精神疾病司法鉴定的特点,进一步规范精神疾病司法鉴定的执业活动,并在此基础之上正确厘清审判职能与鉴定功能的关系,以确保精神疾病司法鉴定活动的顺利进行。     

Finding a voice – the feasibility and impact of setting up a community choir in a forensic secure setting

This study reports on the feasibility and impact of running a choir for forensic psychiatric inpatients, staff and members of the local community, within the confines of a medium secure psychiatric unit. The choir ran between October and December 2013. Eight weekly workshops and a final concert performance were evaluated through participant observation and focus groups held with the participants. Between 12 and 16 male and female patients attended each workshop and the final concert. All participating patients had received a diagnosis of schizophrenia, schizo-affective disorder or personality disorder, all had committed serious violent or sexual offences and all were legally detained and receiving treatment in a forensic medium or low secure ward, under the Mental Health Act (England and Wales). Considerable benefits were reported by patients, as well as by the participating community choir members and staff. Primary benefits reported by patients included the following: improved happiness and well-being; increased confidence and self-esteem; greater emotional connectedness and reduced sense of stigma. Participating staff also reported increased feelings of well-being and happiness, greater tolerance and more positive perceptions of the functioning and capabilities of forensic psychiatric patients. The longer term benefits of music participation on the mental health and social functioning of forensic psychiatric patients require further investigation.     

Not guilty by reason of insanity: clinical and judicial profile of medium and high security patients in Belgium

Under Belgian law, offenders deemed to lack criminal responsibility because of insanity receive mandated treatment under the internment law. Population profiles of these forensic patients (‘internees’) are, however, very scarce. In this study, we analysed the demographic, clinical and judicial profile of a large sample of Belgian internees admitted to a secure setting. In addition, differences between internees admitted to a medium versus a high security setting were investigated. Belgian internees were characterised by a large number of personality disorders and a low number of first offenders. Comparative analyses showed substantial differences between the high and medium security settings, with a marked proportion of the forensic patients in high security having committed a sexual offence. Contrary to expectations, more predictors for length of stay were found in the medium security subsample, while admission periods were significantly longer in the high security subsample.     

Patient characteristics related to length of stay in Dutch forensic psychiatric care

Create an overview of characteristics of patients in long-term forensic psychiatric care (LFPC) with a higher length of stay (LOS) care compared to patients in regular forensic psychiatric care (RFPC) with a shorter LOS. Data were collected from 139 patient records. This study examined whether patients in LFPC differ from patients in RFPC on sociodemographic data, legal data and clinical data and whether those characteristics are able to predict LOS. Patients in LFPC were more often born in a Dutch Caribbean country, less often had a substance abuse disorder, were more often emotionally neglected during childhood, had a higher HCR-20 risk item score, a higher security needs score, a higher (less successful) recovery score, were more often recidivist and had absconded more often than RFPC patients. Certain characteristics were able to distinguish the longer LOS group which might be useful to establish sequel services and enhance treatment efficiency.     

A study of the use of sedative PRN medication in patients at a secure hospital

We have investigated the use of ‘as required’ (PRN), sedative psychotropic medication in 242 forensic rehabilitation patients at a UK secure psychiatric hospital. In total, 176 (73%) patients were prescribed PRN medication and 90 (37%) received a total of 542 doses in the preceding two weeks. The principle indication for use was agitation. Oral benzodiazepines, particularly Lorazepam, were most commonly prescribed and administered followed by Haloperidol. Although high-dose antipsychotics and polypharmacy due to PRN prescribing were common (11 and 20%, respectively), on only 6% of the days studied did patients actually receive PRN antipsychotic medication. Using univariate analyses, PRN administration was associated with younger age, female gender, emotionally unstable personality disorder, shorter length of stay and detention in medium security. Case note documentation of PRN administration was often absent (44%) or vague. Further research, both quantitative and qualitative, is needed into the precise circumstances under which PRN is administered.     

Using the National Diabetes Audit to improve the care of diabetes in secure hospital in-patient settings in the UK

To examine the ability of two forensic units, one high secure and one medium secure, to meet the NICE (National Institute for Health and Care Excellence) standards of care for diabetes. We applied the National Diabetes Audit programme, which uses as standards the NICE guidelines, to assess the quality of care provided for patients in two forensic units. Of the 500 patients, 200 in high secure and 300 in medium secure, 88 (17.6%) had type 2 diabetes. None had Type 1 diabetes. Of those with Type 2 diabetes, the care of 74 (84%) met all 8 NICE recommended standards. Glucose levels were lower in the medium/low secure unit compared to the higher security environment. Whilst achievement of process-based outcomes was higher than those reported nationally, achieving clinical outcomes was more challenging. High-quality diabetic care can be provided for patients in forensic units. Benchmarking physical health outcomes against national criteria in mental health inpatients is a potential method of improving outcomes.     

Associations between ward climate and patient characteristics in a secure forensic mental health service

Ward climate is associated with patient satisfaction and, potentially, with improved outcomes but increased understanding of its relationship with individual patient characteristics is required. We investigated relationships between patient (N?=?63) gender, perceived risk, risk behaviour, therapeutic engagement (session attendance), psychopathology and ward climate in a forensic psychiatric hospital. Lower security levels were significantly associated with better patient cohesion (PC), experienced safety (ES) and therapeutic hold (TH). Female gender predicted PC and ES. Higher perceived risk was associated with lower PC after controlling for security level and gender. Diagnosis of personality disorder or psychosis was associated with higher ES. Lower levels of engagement predicted greater TH. The relationship between patient characteristics and ward climate in forensic settings is complex. Prospective studies are needed to further establish determinants of ward climate, particularly those aspects of patient risk that are associated with poorer PC.     

The impact of forced forensic psychiatric confinement on composition and structure in the personal networks of personality-disordered forensic psychiatric patients

This study explored to what extent the composition and structure of personal networks of personality-disordered forensic psychiatric patients changed before and after forced confinement in a forensic psychiatric centre. Semi-structured in-depth interviews with 36 patients and selected members of their networks were examined. During forensic psychiatric treatment, patients reported a decrease in network size, in the number of high-risk network members, and in the number of social ties between these high-risk network members. Personal relationships were of shorter duration, with lower levels of contact frequency and reciprocity. No changes were observed in the patients’ companionship, practical and emotional support networks. During forensic psychiatric treatment, patients reported some new relationships, especially with persons outside the forensic psychiatric centre. Information on compositional and structural personal network factors over time helps forensic mental health professionals to properly assess and manage the important dynamic social network conditions associated with recidivism.     

Using the Violence Risk Appraisal Guide (VRAG) to predict in-prison aggressive behavior in a Swiss offender population

The present study is a first-time evaluation of the Violence Risk Appraisal Guide's (VRAG) predictive quality for institutional violence in a German-speaking country. The VRAG was assessed for 106 violent and sexual offenders based on their files. Violent infractions during imprisonment were evaluated using the files of the state penitentiary. Results show in accordance with previous studies only a moderate effect between VRAG scores and institutional misconduct. However, these findings were only significant for participants with a sex crime as index offense. In the study, the VRAG was unable to predict verbal and physical violence by violent offenders. The implications of these findings for institutional risk management and the future development of intramural detection of participants at risk in the German-speaking part of Europe are discussed.     

Predicting discharge in forensic psychiatry: the legal and psychosocial factors associated with long and short stays in forensic psychiatric hospitals

In Germany, both the number of patients treated in forensic psychiatric hospitals and the average inpatient treatment period have been increasing for over thirty years. Biographical and clinical factors, e.g., the number of prior offences, type of offence, and psychiatric diagnosis, count among the factors that influence the treatment duration and the likelihood of discharge. The aims of the current study were threefold: (1) to provide an estimate of the German forensic psychiatric patient population with a low likelihood of discharge, (2) to replicate a set of personal variables that predict a relatively high, as opposed to a low, likelihood of discharge from forensic psychiatric hospitals, and (3) to describe a group of other factors that are likely to add to the existing body of knowledge. Based on a sample of 899 patients, we applied a battery of primarily biographical and other personal variables to two subgroups of patients. The first subgroup of patients had been treated in a forensic psychiatric hospital according to section 63 of the German legal code for at least ten years (long-stay patients, n=137), whereas the second subgroup had been released after a maximum treatment period of four years (short-stay patients, n=67). The resulting logistic regression model had a high goodness of fit, with more than 85% of the patients correctly classified into the groups. In accordance with earlier studies, we found a series of personal variables, including age at first admission and type of offence, to be predictive of a short or long-stay. Other findings, such as the high number of immigrants among the short-stay patients and the significance of a patient's work time before admission to a forensic psychiatric hospital, are more clearly represented than has been observed in previous research.     

The Criminogenic,Clinical, and Social Problems of Forensic and Civil Psychiatric Patients

Forensic psychiatric patients consume an increasing proportion of mental health resources in Canada and the United States. To inform mental health policy and practice, we compared the criminogenic, clinical, and social problems of forensic patients to those of civilly committed psychiatric patients in two Canadian studies. We predicted that forensic patients would score higher on criminogenic problems and lower on clinical and social problems than civil patients in two studies: one comparing 83 forensic and 189 civil inpatients on a clinician-completed form, the Resident Assessment Instrument--Mental Health, at an urban mental health center, and the second comparing 423 forensic and 178 civil patients assessed at different times using the Patient Problem Survey. The two studies were quite similar in their findings, despite differences in their samples, measures, and data collection methods. In both studies, forensic patients were similar to or lower than civil psychiatric patients in all criminogenic, clinical, and social problems. We conclude that forensic mental health services would benefit greatly by drawing from knowledge accumulated in the general psychiatric literature. This finding also supports the idea that many forensic patients can be appropriately diverted to nonforensic mental health services.     

Deliberate ingestion of foreign bodies as a form of self-harm among inpatients within forensic mental health and intellectual disability services

Deliberate foreign body ingestion is a significant issue in prison and psychiatric settings. It is associated with serious physical complications, including bowel obstruction, perforation and haemorrhage. Episodes of deliberate foreign body ingestion were identified retrospectively from 5417 incident records from two inpatient forensic services (one mental health and one intellectual disability) over a one year timeframe, using related search terms. Rates were compared according to gender, diagnosis and level of security. Incidents of deliberate foreign body ingestion were found to occur on average every 2.7 days across the study population, with 133 incidents recorded over a one year period, accounted for by 27 patients. Women and patients in lower levels of security were significantly more likely to engage in deliberate foreign body ingestion. Staff responses to this behaviour were highly variable. Deliberate foreign body ingestion occurs frequently within inpatient forensic services, and can have significantly detrimental physical implications for affected patients. Further research should investigate the psychiatric and intellectual disability profile of such individuals in further detail, as well as exploring patient narratives; both of which will help inform development of treatment strategies.     

Homicide by a Forensic Female Sample in Brazil: A Preliminary Study

The objective of the study was to evaluate the mental status of all women (n = 14) who were acquitted by reason of insanity of charges of murder or attempted murder and committed to a forensic psychiatric hospital in the state of Rio de Janeiro, Brazil. All cases were retrospectively examined, including medical files, technical records, and forensic experts' official reports. A conclusive psychiatric diagnosis was established using the Structured Clinical Interview for DSM‐IV Axis I and II Disorders and clinical and forensic records. The most common diagnosis was schizophrenia/schizoaffective disorders (n = 8; 57.3%). Most victims (n = 12; 75%) were close relatives of the patients. We found that 43% (n = 6) of the patients had a previous history of violent behavior. According to the initial psychiatric forensic evaluation, 5 patients (35.7%) had psychotic symptoms. It is expected that a growing understanding of motivational factors underlying homicidal behavior in mentally disturbed female offenders may further the implementation of effective preventive and therapeutic interventions.     

Topographies of forensic practice in Imperial Germany

This article examines the topography and “cultural machinery” of forensic jurisdictions in Imperial Germany. It locates the sites at which boundary disputes between psychiatric and legal professionals arose and explores the strategies and practices that governed the division of expert labor between them. It argues that the over-determined paradigms of ‘medicalization’ and ‘biologization’ have lost much of their explanatory force and that historians need to refocus their attention on the institutional and administrative configuration of forensic practices in Germany. After first sketching the statutory context of those practices, the article explores how contentious jurisdictional negotiations pitted various administrative, financial, public security, and scientific interests against one another. The article also assesses the contested status of psychiatric expertise in the courtroom, as well as post-graduate forensic psychiatric training courses and joint professional organizations, which drew the two professional communities closer together and mediated their jurisdictional disputes.     

First report from the Swedish National Forensic Psychiatric Register (SNFPR)

To the best of our knowledge, the present register is the only nationwide forensic psychiatric patient register in the world. The aim of this article is to describe the content of the Swedish National Forensic Psychiatric Register (SNFPR) for Swedish forensic patients for the year 2010. The subjects are individuals who, in connection with prosecution due to criminal acts, have been sentenced to compulsory forensic psychiatric treatment in Sweden. The results show that in 2010, 1476 Swedish forensic patients were assessed in the SNFPR; 1251 (85%) were males and 225 (15%) were females. Almost 60% of the patients had a diagnosis of schizophrenia, with a significantly higher frequency among males than females. As many as 70% of the patients had a previous history of outpatient psychiatric treatment before becoming a forensic psychiatric patient, with a mean age at first contact with psychiatric care of about 20 years old for both sexes. More than 63% of the patients had a history of addiction, with a higher proportion of males than females. Furthermore, as many as 38% of all patients committed crimes while under the influence of alcohol and/or illicit drugs. This was more often the case for men than for women. Both male and female patients were primarily sentenced for crimes related to life and death (e.g., murder, assault). However, there were more females than males in treatment for general dangerous crimes (e.g., arson), whereas men were more often prosecuted for crimes related to sex. In 2010, as many as 70% of all forensic patients in Sweden had a prior sentence for a criminal act, and males were prosecuted significantly more often than females. The most commonly prescribed pharmaceuticals for both genders were antipsychotics, although more women than men were prescribed other pharmaceuticals, such as antidepressants, antiepileptics, and anxiolytics. The result from the present study might give clinicians an opportunity to reflect upon and challenge their traditional treatment methods.